A nurse is collecting data from an adolescent client 24 hours after admission. Which of the following findings should be reported immediately?
Oxygen saturation of 95% on 1 L oxygen via nasal cannula.
Presence of barrel chest.
Respiratory rate of 32/min.
Hemoptysis of 300 mL.
The Correct Answer is D
Choice A rationale: An oxygen saturation of 95% on 1 L oxygen via nasal cannula is within acceptable ranges, indicating adequate oxygenation for most patients. Normal oxygen saturation values typically range between 95-100%. While slight adjustments might be needed for patients with chronic conditions like COPD, this value does not suggest a critical issue requiring immediate reporting. Monitoring for any declines in oxygen saturation is recommended.
Choice B rationale: The presence of barrel chest often indicates chronic conditions like obstructive pulmonary disease or asthma, linked to air trapping in the lungs over time. While it warrants medical evaluation, it is typically a long-term structural change rather than an acute finding. This symptom does not necessitate immediate reporting unless accompanied by severe respiratory distress or other critical changes in the client’s condition.
Choice C rationale: A respiratory rate of 32/min is above the normal range for adolescents, which is usually 12-20/min. This indicates tachypnea, suggesting respiratory compromise potentially due to hypoxia, acidosis, or infection. While concerning and requiring prompt evaluation, it does not demand immediate reporting compared to hemoptysis, which is more critical due to the risk of airway compromise or hemorrhage.
Choice D rationale: Hemoptysis of 300 mL is a severe and critical finding, indicating significant bleeding within the respiratory tract. This can result from conditions like tuberculosis, pulmonary embolism, or lung malignancies. Immediate reporting is necessary due to the risk of airway obstruction, hypovolemic shock, or respiratory failure. Swift intervention is crucial to manage the bleeding and prevent life-threatening complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Drying clothing in a hot dryer for at least 20 minutes effectively kills head lice and nits, which are sensitive to high temperatures. Heat disrupts the lipid membranes of lice and dehydrates the eggs, preventing further infestation. This intervention ensures that both live organisms and their offspring are eradicated.
Choice B rationale
Nonwashable items should be sealed in a plastic bag for 14 days, not 7, to ensure the life cycle of lice is interrupted completely. Lice can survive for up to 10 days without a host. This extended duration ensures that any eggs present hatch and the lice perish in the sealed environment.
Choice C rationale
Antibacterial solutions are ineffective against lice and nits, as these organisms are not bacteria. Proper disinfection requires soaking combs and brushes in very hot water or specific insecticidal solutions that target lice. This method disrupts their cellular structure, leading to death.
Choice D rationale
Washing clothing and bed linens in water at 100°F (37.7°C) is insufficient to kill lice, as they can withstand this temperature. Water temperatures should be at least 130°F (54.4°C) to be effective. This ensures complete eradication through thermal inactivation of both adult lice and nits.
Correct Answer is C
Explanation
Choice A rationale
The dorsogluteal muscle is not recommended for vaccine administration in toddlers due to its proximity to the sciatic nerve and potential for injury. The anterolateral thigh is the preferred site due to the presence of thicker muscle layers in younger children.
Choice B rationale
Massaging the injection site is not necessary and may lead to irritation or increased discomfort. Vaccine administration guidelines emphasize minimizing trauma to the site rather than stimulating the area post-injection.
Choice C rationale
Obtaining informed consent is essential before administering any vaccine. This step ensures legal and ethical compliance, allowing guardians to understand the risks and benefits associated with the immunization.
Choice D rationale
Aspiration is no longer recommended in vaccine administration according to updated guidelines. Aspiration increases injection time and patient discomfort without evidence of enhancing safety.
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